CMS proposes extending electronic prior authorization standards to drugs

The Centers for Medicare & Medicaid Services published a proposed rule on April 14, 2026 that would push prior authorization for prescription drugs onto standardized electronic systems across Medicare Advantage, Medicaid, CHIP and Affordable Care Act Exchange plans ^[1]. The rule, numbered CMS-0062-P and running 173 pages in the Federal Register, was open for public comment until June 15, 2026 ^[1].

Prior authorization is the step where an insurer requires a doctor to justify a prescription before agreeing to pay for it. It is a common hurdle for GLP-1 drugs, though the CMS fact sheet and Federal Register listing do not single out any specific drug or drug class ^[1][2].

What the rule would change

A 2024 CMS final rule already required these plans — which CMS calls "impacted payers" — to build Patient Access, Provider Directory, Provider Access, Payer-to-Payer and Prior Authorization application programming interfaces (APIs) ^[2]. But those prior authorization requirements covered non-drug items and services only ^[2]. The new proposal would extend many of them to drugs.

For drugs billed under a medical benefit — the kind administered in a clinic or doctor's office — CMS proposes that payers fold coverage rules and documentation requirements into their existing Prior Authorization API beginning October 1, 2027 ^[2].

For drugs filled at a pharmacy, CMS proposes that state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities and Qualified Health Plan issuers on the Federally-facilitated Exchanges support three National Council for Prescription Drug Programs standards — SCRIPT, Formulary & Benefit, and Real-Time Prescription Benefit — also beginning October 1, 2027 ^[2]. CMS says this would align those plans with requirements Medicare Part D sponsors already follow, and would let prescribers look up formulary information, see real-time coverage details, and send prior authorization requests and receive decisions electronically ^[2].

CMS also proposes adding small group market QHP issuers on the Federally-facilitated Small Business Health Options Program (FF-SHOP) to the list of impacted payers subject to both the earlier rules and these new proposals ^[2].

The decision clocks

The proposal would set deadlines for answering drug requests in some programs. State Medicaid fee-for-service programs, Medicaid managed care plans and CHIP managed care entities would have to decide drug prior authorizations within timeframes matching existing rules — no later than 24 hours after receiving a request for covered outpatient drugs, or 7 days for standard requests and 72 hours for expedited requests for items and services ^[2]. State CHIP fee-for-service programs would also face a 24-hour notice requirement ^[2]. The portion of the CMS fact sheet text available here is cut off before it describes any Medicare Advantage drug decision timeframes, so those details are not confirmed by these sources.

Separately, HHS proposes adopting HL7 FHIR standards for prior authorization transactions under HIPAA, which would reach all HIPAA covered entities that exchange these requests electronically ^[2]. Those entities would have to comply no later than 24 months after the final rule's effective date, with small health plans getting 36 months ^[2]. Entities that do not use electronic prior authorization would not be required to adopt the standards ^[2].

Why it matters for patients

Much of the delay patients experience with a prior authorization comes from paperwork moving by fax, phone and portal between a prescriber's office and a plan. Standardized electronic exchange is meant to let a clinician see coverage and documentation rules at the point of prescribing and send required records without guessing, which CMS says would enable real-time data exchange and speed up decisions ^[2].

This is a proposal, not law. Nothing changes for any prescription today, and CMS has not said when or whether it will issue a final rule. The proposal also does not change what any plan covers or what it requires before approving a drug — it addresses how the request travels and, in Medicaid and CHIP, how fast an answer must come ^[2].

What happens next

Comments closed June 15, 2026 ^[1]. If finalized as written, the Prior Authorization API and NCPDP pharmacy standards requirements would take effect October 1, 2027, the same date CMS proposes for additional implementation guides ^[2]. ONC separately proposes that certain older versions of adopted standards would expire January 1, 2028 ^[2].